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v 2007 <br /> IV <br /> fmo�tNT <br /> ENVIRONMENTAL HEALTH DEPARTM HEALTH <br /> SAN JOAQUIN COUNTY PERIOIT/SERVICES <br /> 304 East Weber Avenue,Third Floor, Stockton, California 95202 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT LIPIPING REPAIR/RETROFIT LIUDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> G Facility Name Phone# <br /> � Address <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Phone# <br /> C #Phone Contractor Name <br /> o ! � �;2 <br /> N <br /> T Contractor Address d1' C (\ CA Lic# ��/'�j� U Class <br /> A Insurer <br /> �'l(v1 /C e�r-L ,l�c.� � �G yy( rc�2 ' Work Comp# <br /> TICC Technician's Certification Number Expiration Date �_ 08 <br /> R <br /> R ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> L _Approved L_Approved with conditions Disapproved <br /> L .(See Attachment With Conditions) <br /> N Plan Reviewers Name /"Date (o'��I 0? <br /> APPLICANT MUST PERFORM ALL WORK iN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AN'D RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature Title oil L C, ` Date Cs a"/ <br /> BILLING INFORMATION: 61 <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 8/8/06) <br /> 1 <br />